Provider Demographics
NPI:1639161607
Name:BERETTA, MICHAEL JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BERETTA
Suffix:
Gender:M
Credentials:PT
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3840 EL DORADO HILLS BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-4567
Mailing Address - Country:US
Mailing Address - Phone:916-941-2440
Mailing Address - Fax:916-941-2450
Practice Address - Street 1:3840 EL DORADO HILLS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-4567
Practice Address - Country:US
Practice Address - Phone:916-941-2440
Practice Address - Fax:916-941-2450
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT269620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP96959Medicare UPIN